HomeMy WebLinkAboutPlumbing Permit �
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� � �� . . � APPLICATION FOR PERMIT TO DO PLUMBING i
a�? 9'� TOWN OF YAR�UTH �oFF,�E �SE oN�,,> '
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' � , � Fee: $ ��� �} c�i� .
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j ' _ � �/ � � � PERMIT NO.P �`J'"�� I '
, By__ __ L.Z--' -- �n 3 af 3 Date �� 20 G�_
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Building / / Owner's J �� �',i�--�
AT: Location� l� �/ � �hc>,� �{����i�c! Name
Type of Occupancy
New❑ Renovation❑ Replacement Ga-^
Plans Submitted Yes� No❑
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BASE
1eS 1 ST FLOOR
�I� 2ND F�OOR
���� 3RD FLOOR
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. (PRINT OR TYPE) �� Check One:
Installing Company Name ���e.r_ �a/�c.� ❑ Corp.
Address �'���-- �'�"� �' ❑ Partnership
- �--.�� O�rm/ ompany
Business Telepho e'� L1,_�7 7 �s Name of Licensed Plumber � �t r c�-r� c ,
INSURANCE COVERAGE: I have a current Iiabiiity insurance policy or its substantial equivalent. Check One: Yes Q�(o O
It you have checked YES, please indicate the type of coverage by C . g the appropriate box.
A liability insurance policy Other type of indemnity � �, Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee dces not fiave the i�surance coverage requiretl by Chapter 142 of
the Mass. General taws, and thai my signature on this permif application waives this requirement.
Check on Owner � Agent ❑
Signature ofOwner orOwnePs Agent �
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1 hereby certify that all of the details and Informatton 1 have submitted Signature of Licensed
(or entered) in above applicatfon are true and accurate to the best of Plumber
my knowledge and that ali plumbing work and instatlations performed
under Pe[mit issued tor this appiicatlon wili be In compliance with all 1 ;3 � G �
pertinant provisions of the Massechusetts State Plumbing Code and Lcense Number
Chapter 142 of the General Laws. Type: MasterE�-' Journeyman❑